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<!-- Author:  Jeremy Sanderlin 
     Date Created: 2006-11-02
     Last Modified: 2006-11-14
     Last Modified By: Jeremy Sanderlin
-->

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<title>Untitled Document</title>
<link rel="stylesheet" type="text/css" href="css/autism292.css" />
<style type="text/css">
	.error{color:#FF0000;font-weight:bold;}
</style>
<script type="text/javascript" src="javascript/checkRequiredFieldsErrorMessages.js"></script>
</head>

<body>
<div id="pagewidth">
    <div id="header">
        <center>
            <img src="images/ASAGGC_Logo_Banner.gif" alt="Autism Society of America - Greater Georgia Chapter" />
        </center>
        <br />
        <br />
    </div>

    <div id="wrapper" class="clearfix">
        <div id="twocols" class="clearfix">
            <div id="maincol">
                <p>
                    Thank you for choosing to register for a customizable content portal.  Please take a moment
                    to complete this application form.
                </p>
                
                <hr />
                <form action="AutismSiteMasterController" method="post" onsubmit="return checkRequiredFields();">
                    <input type="hidden" name="action" value="register">
                            
                            <label>First Name</label><input type="text" id="first_name" name="first_name" />
                            <span class="error">&nbsp;</span>
                            <br />
                            <label>Last Name</label><input type="text" id="last_name" name="last_name"  />
                            <span class="error">&nbsp;</span>
                            <br  />
                            <hr />
                        <fieldset title="Your Address (Optional)"><legend>Your Address (Optional)</legend>
                            <label>Address Line 1</label><input type="text" id="address_1">
                            
                            <br />
                            <label>Address Line 2</label><input type="text" id="address_2">
                            <br />
                            <br />
                            <label>City</label><input type="text" id="city">
                            
                            <br />
                            <label>State</label><input type="text" id="state">
                            
                            <br />
                            <label>Zipcode</label><input type="text" id="zipcode">
                            
                        </fieldset>
                            <br />
                            <hr />
                            <fieldset title="Your Email Address (Required)"><legend>Your Email Address (Required)</legend>  
                                Email Address
                                <br />
                                <input type="text" id="email_1" name="email_1"  />
                                <span class="error">&nbsp;</span>
                                <br  />
                                Re-Type Email Address
                                <br />
                                <input type="text" id="email_2" name="email_2"  />
                                <span class="error">&nbsp;</span>
                            </fieldset>
                            <br />
                            <hr />
                            <fieldset title="Please Create A Password (Required)"><legend>Please create a password (Required)</legend>
                                Password:<br />
                                <input type="password" id="pass01" name="pass01">
                                <span class="error">&nbsp;</span>
                                <br />
                                Re-type Password:<br />
                                <input type="password" id="pass02" name="pass02">
                                <span class="error">&nbsp;</span>
                            </fieldset>
                            <br />
                            <hr />
                        <input type="submit" value="submit" />
                        <input type="reset">
                    
                </form>
            </div>
        </div>
    </div>
</div>
</body>
</html>

